INSURANCE CERTIFICATE REQUEST FORM - Novick Group, Inc.

INSURANCE CERTIFICATE REQUEST FORMPlease complete a separate form for each certificate requested.INFORMATION ABOUT YOUInsured Name: __________________________________________________________________________________Chapter Name if applicable:________________________________________________________________________Address: ______________________________________________________________________________________City: __________________________________ State: ______________________ Zip: _______________________Phone: ________________________________ Fax: ___________________________________________________Email:_________________________________________________________________________________________Person Completing this Form (Please print): ____________________________________________________________Signature:____________________________________________Date of Request: ____________________________INFORMATION ABOUT REQUIRED CERTIFICATE(S)LandlordLeased EquipmentLease/Contract No.: ___________________________________ Estimated Value of Equipment: ________________Special EventName of Event: _______________________________________Date of Event: ______________________________Location of Event (List street address if available): _____________________________________________________________________________________________________________________________________________________________________Type of Event (Run, Bike, Dinner, meeting, etc.): __________________________________________________________Describe your Participation in Event: _________________________________________________________________Projected number of participants: _________________________Number of volunteers working on event: __________Will alcohol be available Yes No If yes, who will provide/sell: _____________________________________Please be advised: Events that involve certain categories of risks (eg., sporting events, golf tournaments, eventsincluding children, alcoholic beverages, number of participants, etc.) may be charged an additional premium.Other: ____________________________________________________________________________________________________________________________________________________________________1

INFORMATION ABOUT CERTIFICATE HOLDERFull name and address of organization or entity requiring certificate(s)(We will send certificate TO YOU, but must show the following certificate holder address on the certificate):Name: ________________________________________________________________________________________Address:_______________________________________________________________________________________City: __________________________________ State: ______________________ Zip: _______________________What is this organization’s involvement? ____________________________________________________________________________________________________________________________________________________________Is this organization requesting to be named as an Additional Insured? Yes NoIf yes, Additional Insured – exact language as required by certificate holder (if unsure, you may attach assumption ofliability documents or contract):____________________________________________________________________________________________________________________________________________________________________________________________Is this organization requesting to be named as a Loss Payee? Yes NoIf yes, please describe: _________________________________________________________________________________________________________________________________________________________________________CONTACT TO FAX OR EMAIL CERTIFICATE(S)Name: ________________________________________________________________________________________Fax: __________________________________ E­mail: _________________________________________________Name: ________________________________________________________________________________________Fax: __________________________________ E­mail: _________________________________________________Name: ________________________________________________________________________________________Fax: __________________________________ E­mail: _________________________________________________Fax request to: Attn: Certificates – Fax# 301­795­6610OrEmail to: certificates@novickgroup.comPlease allow at least 48 hours to process request.2